Brain Injury

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Brain Injury
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Concept Map Selected Topics in Neurological
Nursing
PATHOPHYSIOLOGY Traumatic Brain Injury Spinal
Cord Injury Specific Disease Entities
Amyotropic Lateral Sclerosis Multiple
Sclerosis Huntingtons Disease
Alzheimers Disease Huntingtons Disease
Myasthenia Gravis Guillian-Barre Syndrome
Meningitis Parkinsons Disease
PHARMACOLOGY --Decrease ICP --Disease Specific
Meds
ASSESSMENT Physical Assessment Inspection
Palpation Percussion
Auscultation ICP Monitoring Neuro Checks Lab
Monitoring
Care Planning Plan for client adls, Monitoring,
med admin., Patient education, morebased On
Nursing Process A_D_P_I_E
Nursing Interventions Evaluation Execute the
care plan, evaluate for Efficacy, revise as
necessary
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Objectives

• Recall anatomy and physiology of the brain
  cranial nerves
• Explain pathophysiology of various brain (head)
  injuries
• Detail signs, symptoms and prevention of
  Increased Intracranial Pressure (ICP)
• Demonstrate effective use of Glasgow Coma Scale
• Discuss medical nursing management of brain
  injuries

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Sometimes The Lights are on. But nobodys
home.
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Anatomy Physiology Review
O O O T T A F A G V S H
I II III IV V VI Vii VIII IX X XI XII
lfactory ptic culomotor rochlear rigeminal bducens
acial coustic lossopharyngeal agus pinal
accessory ypoglossal
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Cranial Nerve Function Structures Innervated
I Olfactory Smell Olfactory Bulb
II Optic Vision Retina
III Oculomotor Eyeball movement Lens Accomodation Pupil Constriction 4 eyeball muscles 1 eyelid muscle
IV Trochlear Eyeball Movement Superior Oblique Muscles
V Trigeminal Sensation General Sensory From Tongue Proprioception Face, scalp, teeth, lips, eyeballs, nose, throat lining Anterior 2/3 of tongue Muscles of mastication
VI Abducens Eyeball movement Lateral Rectus muscle
VII Facial Taste Proprioception Facial Expressions Salivation Lacrimation Face Scalp Face Scalp Muscles of face Salivary Lacrimal Glands
VIII Acoustic Balance Hearing Vestibular apparatus Cochlea
IX Glossopharyngeal Taste Proprioception for swallowing Blood pressure receptors Swallowing gag reflex Tear production Saliva production Posterior 2/3 of tongue Throat muscles Carotid sinuses Throat muscles Lacrimal glands Parotid glands
X Vagus Chemoreceptors Pain receptors Sensations Taste Heart Rate Stroke Volume Peristalsis Air Flow Speech Swallowing Blood O2 Concentration, Aortic bodies Respiratory Digestive Tracts External ear, larynx, pharynx Tongue Pacemaker Ventricular Muscles Smooth muscles of digestive tract Smooth muscles of bronchioles Muscles of larynx pharynx
XI Spinal Accessory Head rotation, upright position Shrugging shoulders 1. Trapezius sternocleidomastoid muscles
XII Hypoglossal Speech Swallowing Tongue Throat muscles
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Brain Trauma

• Brain injury results in more trauma deaths than
  do injuries to any other body region!

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Primary Injury

• Mechanical trauma that occurs at the moment of
  impact and may lead to irreversible cell damage
  from physical disruption of neurons or axons

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3 Top Causes
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Risk Factors

• Highest in young people and the elderly
• Age 65 75 has highest incidence of HI of ALL
  age groups
• Occurs twice as often among males compared with
  females
• Motor vehicle crashes account for the major
  proportion of head and brain injuries.and
  involve a disproportionately large number of
  young persons
• Alcohol intoxication is a compounding factor in
  at least 30 to 50 of head injuries and is a
  contributing factor in almost ½ of all fatal
  motor vehicle crashes in the United States

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Did you Know ?

• Laws that require helmet use have been shown to
• reduce deaths
• in motorcyclists
• by about 30

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Boxing Coup- Contre Coup Injury The second
collision
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Rear-Ended Whiplash Effect
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At the Scene - EMS- First Responders
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• 1. Maintain ability to breathe
• 2. Prevent shock
• 3. Immobilization to prevent further spinal cord
  damage
• (Backboard C-Collar)

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EMS type C- Collar
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Spinal Injury Assumed With Any Head Injury
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EMS Back Boards
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Upon Arrival to ER
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Baseline Assessment

• Vital Signs
• Glasgow Coma Score (GCS)

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The GCS is the most widely used method of
defining a patient's Level of Consciousness (LOC)
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• Everybody
• Check
• Hand Grasps for Motor Strength
• by
• CROSSING

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Oculocephalic Reflex (Dolls Eye)
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OCR
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C Spine X-RayCross-Table LatBefore removal
of ANY immobilization devices
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As Much as Possible In ER

• Instruct client to avoid sneezing or coughing
• Provide calm environment
• Maintain immobilization
• Avoid meds the decrease LOC such as analgesics

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Severity of Head Injury

• GCS 3 8 Severe Head Injury
• GCS 9 12 Moderate Head Injury
• GCS 13 -15 Mild Head Injury

GCSSCORE lt 8 COMA
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• The best guide to
• the severity of head injury
• is the level of consciousness

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History of Injury

• Loss of Consciousness?
• Other victims seriously hurt?
• Mechanism of injury?
• Driver / passenger / seatbelt ?
• Fall height / what caused fall?
• Hit where and with what?
• Gunshot / impaled object ?

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Open or Closed Injury ?
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Diagnostics

• Damaged areas of the brain have a reduced or no
  blood flow or glucose metabolism. This can be
  seen in the images below where there has been a
  blow to the head by a rock

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Skull Fractures

• Present on CT scans in about two thirds of
  patients after head injury
• Skull fractures can be linear, depressed, or
  diastatic and may involve the cranial vault or
  skull base

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Depressed Skull Fractures

• A portion of the skull is extending into the
  intracranial space
• Often results in pressure on the brain or direct
  injury to the brain
• In addition, the bone fragment may cause a
  laceration of the dura mater resulting in a
  cerebrospinal fluid leak
• Outcome is based upon the underlying brain
  injury. If no brain injury is present the surgery
  represents a cosmetic procedure and the outcome
  is generally quite good

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Frontal Lobe- associated with reasoning,
planning, parts of speech, movement, emotions,
and problem solving Parietal Lobe- associated
with movement, orientation, recognition,
perception of stimuli Occipital Lobe-
associated with visual processing Temporal
Lobe- associated with perception and recognition
of auditory stimuli, memory, and speech
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Basal Skull Fractures

• Clinical Clues may include
• CSF leakage through the ear or nose (otorrhea or
  rhinorrhea)
• Hemotympanum (blood behind the eardrum)
• Bruising behind the ears (postauricular
  ecchymoses)
• Battle Sign
• Bruising around the eyes (periorbital ecchymoses)
• Raccoon Eyes Panda
  Eyes
• Injury to cranial nerves
• VII Facial nerve - weakness of the face
• VIII Acoustic nerve - loss of hearing
• I Olfactory nerve - loss of smell
• II Optic nerve - vision loss
• VI Abducens nerve - double vision

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Basal Skull Fractures
Involve the floor of the skull and include
fractures of the cribriform plate, frontal bones,
sphenoid bones, temporal bone and occipital bones
1 frontal2 ethmoid3 sphenoid4 temporal5
parietal6 occipital
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• 1. Frontal sinus
• 2. Crista galli
• 3. Cribriform plate
• 4. Lesser wing of sphenoid
• 5. Superior orbital fissure
• 6. Superior border of petrous part of temporal
  bone
• 7. Dense shadow of petrous part of temporal bone
• 8. Perpendicular plate of the ethmoid
• 9. Vomer
• 10. Maxillary sinus
• 11. Inferior concha
• 12. Ramus of mandible
• 13. Body of mandible

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CSF Leakage

• Rhinorrhea and otorrhea are clinical signs of
  cerebrospinal fluid (CSF) leakage in patients
  with skull fracture
• Presence of glucose (CSF) in otorrhea and
  rhinorrhea detected by Beta-2 transferrin.
  Nasal/ear discharge (glucostix) was traditionally
  used to diagnose CSF leak at the bedside, but has
  fallen into disuse as it has poor positive
  predictive value
• CSF leakage opens the brain spinal canal to
  infection
• CSF is needed to cushion the brain, maintain
  pressure within the eye and cleanse the CNS (like
  the lymphatic system serves the same function in
  the rest of the body) 

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Halo Effect of CSF
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Prevent Infection !

• Cover any suspected source of
• CSF leakage with a
• Sterile Dressing STAT !

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CSF Infection

• Nuchal Rigidity
• CSF has WBCs
• Increased Temperature

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Basal Skull Fractures

• Most basal skull fractures do not require
  treatment and heal themselves
• Persistent CSF leakage may warrant operative
  repair of the leakage, particularly CSF leaks
  related to frontal bone and cribiform plate
  fractures

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Associated with Brain Injury

• Blood in the anterior chamber of the eye
  (hyphaema) as a complication of blunt trauma.
  Eyes with hyphaema may show other signs of damage

Blood on Ocular Surface
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Another Clue.
Avulsed eye and lacerations to the forehead
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Penetrating Brain Injury
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Head Injury Assessment

• Obvious Skull Fractures?
• Lacerations?
• Deformities? (bumps / indentations)
• Facial Injuries?
• Blood and/or CSF drainage from nostrils?
  (rhinorrhea)
• Blood and/or CSF drainage from ear canals?
  (otorrhea)
• Blood and/or CSF drainage from mouth?
• Blood and/or CSF drainage from eyes?
• Pain?
• Headache?

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Collaborative Treatment Goals

• Maintain
• Airway
• Breathing
• Circulation
• Maintain cerebral perfusion
• Maintain electrolyte balance
• Maintain fluid balance
• Maintain cognitive function
• HOW ????

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• Prevent Secondary Injury !!!
• Meaningful recovery of function after head injury
  is possible IF secondary injuries are prevented
  or minimized